r-.kPUS lAK.AAN KAM..-uS UNJVERSfTJ SAINS MALAYSIA FINAL R EPORT US M SHORT TERM G RANT GRA NT NO : 304/PPSP/6131115 AN INTERVENTIVE AND KAP STUD Y ON HEALTHY LIFESTYLE OF OVERWEIG· HT AND UNCONTROLLED DIABETIC PATIENTS IN KOT A 81-IARU, KELANT AN I JUN 2000 - 30 NO VEMBER 2002 RESEA RCHERS ASSOC PROF AZIZ AL- SAFI ISMAI L (H EAD) PROF MAFAUZY MO HA MED PRO F RUSLI NORD IN PROF WAN A BDUL MANAN WAN M UDA DR NOOR BBRA HI M MOHD SAK I AN
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r-.kPUS lAK.AAN KAM..-uS KESIHA f-~ UNJVERSfTJ SAINS MALAYSIA
FINAL REPORT
USM SHORT TERM GRANT
GRANT NO : 304/PPSP/6131115
AN INTERVENTIVE AND KAP STUDY ON HEALTHY LIFESTYLE OF OVERWEIG·HT
AND UNCONTROLLED DIABETIC PATIENTS IN KOT A 81-IARU, KELANT AN
I JUN 2000 - 30 NOVEMBER 2002
RESEA RCHERS
ASSOC P ROF AZIZ AL-SAFI ISMAIL (H EAD) PROF MA FAUZY MOHA MED
PROF RUSLI NORDI N PROF WAN ABDUL MANAN WAN M UDA
DR NOOR BBRA HIM MOHD SAKIAN
FINAL REPORT
USM SHORT TERM GRANT
GRANT NO: 304/PPSP/6131115
AN INTERVENTIVE AND KAP STUDY ON HEALTHY LIFESTYLE OF OVERWEIGHT
AND UNCONTROLLED DIABETIC PATIENTS IN KOTA BHARU, KELANTAN
1 JUN 2000- 30 NOVEMBER 2002
RESEARCHERS
ASSOC PROF AZIZ AL-SAFI ISMAIL (HEAD) PROF MAFAUZY MOHAMED
PROF RUSLI NORDIN PROF WAN ABDUL MANAN WAN MUDA
DR NOOR IBRAHIM MOHO SAKIAN
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LAPORAN AKHIR· PROJEK PENYELIDIKAN
R&D JANGKA PENDEK
A. MAKLUMAT AM
Tajuk Projek: An Interventive And KAP Study On Healthy Lifestyle Of Overweight
And U neon trolled Diabetic Patients In Kota Bharu, Kelantan.
Tajuk Program:
Tarikh Mula: I Jun 2000-30 November 2002
Nama Penyelidik Utama: Prof Madya Aziz Al-Safi Ismail ( berserta No. KIP)
3) Prof Wan Abdul Manan Wan Muda 4) Dr. Noor Ibrahim
B. PENCAPAIAN PROJEK:
UC: 571104-03-5419
1/C : 561115-03-5757 I/C: 550508-10-5791
(Sila tandakan [/] pada kotak yang bersesuaian dan terangkan secara ringkas di dalam ruang di bawah ini. Sekiranya perlu, sila gunakan kertas yang berasingan)
Penemuan asli/peningkatan pengetahuan
Physical exercise can improve glycaemic control of patients with diabetes in Tropical Countries.
Rekaan atau perkembangan produk baru,
(Sila beri pel~je/asan;makluman agar mudah dikomputerkan)
(I)
(2)
Mengembangkan proses atau teknik baru,
(Sila beri penjelasanlmakluman agar mudah dikon1puterkan)
(1) Structured exercise for patient with diabetes.
Memperbaiki/meningkatkan produklproses/teknik yang sedia ada
(Sila beri penjelasan/makluman agar mudah dikomputerkan)
(1)
(2)
C. PEMINDAHAN TEKNOLOGI
Berjaya memindahkan teknologi.
Nama Klien:
(Nyatakannama
penerima pemindahan teknologi
ini dan sama ada daripada
pihak swasta ataupun sektor
awam)
Berpotensi untuk pemindahan teknologi.
(l)
(2)
(3)
Tiada
(Nyatakan jenis klien yang mungkin berminat)
D. KOMERSIALISASI
Berjaya dikomersialkan. Tiada
Nama Klien:
Berpotensi untuk dikomersialkan.
(Nyatakan jenis klien yang mungkin berminat)
E. PERKHIDMATAN PERUNDINGAN BERBANGKIT DARIPADA PROJEK
(Klien dan }en is penuuiingan) Tiada
(I)
(2)
F. PATEN/SIJIL INOVASI UTILITI
(Nyatakannombor dan tarikh pendaftaran paten. Sekiranya patenlsijil iliovasi uti/iii Ielah dipohon tetapi masih belum didaftarkan. si/a berikan nombor dan tarikhjail paten).
Tiada
G. PENERBITAN BASIL DARIPADA PROJEK
(i) LAPORAN/KERTAS PERSIDANGAN ATAU SEMINAR
(1) MASO
(2) Natioanal Conference
(ii) PENERBIT AN SAINTIFIK
(I)
(2)
H. HUBUNGAN DENGAN PENYELIDIK LAIN
(sama ada dengan institusi tempatan ataupun di luar negara)
(I) Universiti Kebangsaan Malaysia
(2)
I
..
I. SUMBANGAN KEWANGAN DARI PIHAK LUAR
(Nyatakan nama agensi dan nilai atau peralatan yang telah diberi)
Tiada
J. PELAJAR IJAZAH LANJUTAN
(Nyatakan jum/ah yang telah ·dilatih di dalam bidang berkaitan dan sama ada diperingkat sarjana atau Ph.D).
Nama Pelajar
Sarjana
Dr. Noor Ibrahim Mohamed Sakian
Ph.D
K. MAKLliMAT LAIN YANG BERKAITAN
Tarikh Tandatan~ Professor Zabid'~~~ar Mohd. Hussin Chairman of Research & Ethics Committeo
School of Medieal Sciences Health Campus
Unho;ersiti Sains Malaysia 16.150 Kuhang Kerian.
KBLANTAN, l\1ALAYSIAi
TANDATANGAN PENGERUSI
JA WATANKUASA PENYELIDIKAN
Sarjana Sains Sukan
------PUSJtT-PENG:A-nA:
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TABLE OF CONTENTS
ABSTRACT XI
Chapter l INTRODUCTION
1.1 Introduction
1.2 Study Hypothesis .. 3
1.3 Objectives 3
1.4 Study Expectations 4
Chapter 2 LITERATURE REVIEW
2.1 Diebetes Mellitus 5
2.2 Classification of Diabetes Mellitus 5
2.3 Diagnosis of Diabetes Mellitus 9
2.4 Management of Diabetes Mellitus 9
2.4.1 Diet 10
2.4.2 Oral Hypoglycaemic Agents 10
2.4.3 Insulin II
2.5 Type 2 Diabetes Mellitus II
2.5.1 Pathogenesis and Natural History II
2.5.2 Associated Disorders 12
2.5.3 Physical Activity and Type 2 Diabetes 15
2.5.4 Recommendations For Exercise in Type 2 Diabetes 18
2.5.5 Exercise Prescription for Individuals with Type 2 Diabetes 18
2.5.6 Monitoring Intensity of Exercise 22
2.5.7 Resistance training 22
2.5.8 Warm-up and Cool-down 23
2.6 Exercise Recommendations for Blood Glucose Management 23 -
2.7 Managing Diabetic Complications 24
Chapter3 MATERIAL AND METHODS
3.1 Subjects 26
3.2 Sampling 26
3.3 Study Design 27
3.4 Assessments 27
3.4.1 Anthropometric and Blood Analysis 27
3.4.2 Cardiorespiratory Fitness Assessment 28
3.5 Exercise Programme 29
3.5.1 Warm-up Phase 30
3.5.2 Exercise Phase 30
3.5.3 Cool-down Phase 31
3.6 Statistical Analysis 31
Chapter4 RESULTS
4.1 Subjects 32
4.2 Knowledge, Attitude and Practice Questionnaire Results 34
4.2.1 Knowledge Scores 34
4.2.2 Attitude Scores 35
4.2.3 Practice of Exercise Scores 35
4.3 Anthropometric, Body composition and Biochemical Results
4.3.1 Body Mass Index
4.3.2 Body Fat Percentage and Fat Free Mass
4.4 Blood Pressure
4.5 Fasting Plasma Glucose
4.6 Glycosylated Hemoglobin
4.7 Lipid Profile
4.8 Fasting Insulin
4.9 Fasting C-Peptide
4.10 Cardiorespiratory Fitness
4.11 Resting Heart Rate
Chapter 5 DISCUSSION
5.1 Body Mass Index and Body Composition
5.2 Blood Sugar Control
5.3 Fasting Plasma Insulin and C-Peptide Level
5.4 Lipid Profiles
5.5 Blood Pressure
5.6 Cardiorespiratory Fitness
5.7 Knowledge, Attitude and Practice Study
5.8 Limitations of Study
CONCLUSION AND RECOMMENDATIONS
BIBLIORAPHY
40
40
40
42
42
43
43
44
44
44
45
46
48
49
50
50
52
52
53
54
57
APPENDICES
Appendix I Progress Report 67
Appendix II Abstract Submission Form 70
-· Appendix III Exercise Log Book 71
Appendix IV Statement Report 72
Appendix V Ab~tract 73
ABSTRACT
OBJECTIVES: To assess the effects of a regular exercise programme on metabolic
control and also knowledge, attitude and practice (KAP) of exercise and physical
activity among Type 2 diabetes mellitus patients.
MATERIAL AND MET{{ ODS: Forty two Type 2 diabetes patients from the
community medicine and medical specialist clinics in USM were assigned . to two
groups; The interventive group consisted of 13 males and 14 females, mean age
52.6(8.7) (mean (SD)), body mass index 27.2 (3.9) participated in regular group
exercise sessions (3 times a week, 1 hour sessions) for 7 weeks. Exercise intensity was
predetermined based on the predicted target heart rate for each subject. The control
group consisted of 7 males and 8 females, mean age 56.5(11.1), body mass index
25.8(2.73). Pre and post-intervention anthropometric measurements and blood
investigations were done. These include height, weight, body mass index, body fat
percentage and fat free mass (FFM), blood pressure, cardiorespiratory fitness level,
fasting plasma glucose level (FPG), HbA I c level, fasting lipid profile, insulin and C
peptidelevel.
RESULTS:, In the intervention group, FFM increased from 45.98(9.71) to 47.93(10.53)
kg,; percentage body fat decreased from 32.37(11.02) to 30.14(10.73)%. Diastolic
pressure reduced from 91(11.2) to 83.3(7.5) mmHg, cholesterol level decreased from
6.23(1.03) to 5.74(1.23) mmoVI, HDL level increased from 0.97(0.31) to 1.19(0.28)
mmolll. Estimated V02max increased from 21.6(7.04) to 27.7(8.72) mllkg/min. Resting
heart rate declined significantly from 80(7) to 73( II) bpm. There was no improvement
in body mass index (BMI), fasting plasma glucose, insulin and C-peptide levels.
Knowledge and attitude scores were higher than practice scores.
XI
CONCLUSION: Seven weeks of exercise intervention among type 2 diabetes patients
resulted in an improvement in body composition, cardiorespiratory fitness, lipid profile
and a reduction in blood pressure. However there is a disparity between knowledge and
practice of exercise and physical activity.
xii
1.1
CHAPTER I
INTRODUCTION
Recent figures from Diabetes Adas 2000 published by the International Diabetes
Federation (IDF) revealed that over 150 million adults around the world have diabetes,
an II% increase in just ~ years (1995-2000)(IDF, 2000). The prevalence of diabetes is
presently higher in developed countries than in developing countries, but the developing
world will be more seriously affected by the escalating diabetes epidemic in the future.
Even more alarming is the increasing numbers of younger (and productive) diabetics
seen especially in developing countries. This substantial rise in diabetes is contributed
to the urbanisation, westemisation and economic development in developing countries
(Jerval, 1997). The above changes inadvertently bring about concomittant changes in
lifestyle and diet, the two most important external contributing factors for type 2
diabetes. Morbidity and mortality in type 2 diabetes is mainly due to cardiovascular
disease, as a result of hypertension, dyslipidemia, smoking, obesity and lack of exercise
(Fuller et al, 1983). In Malaysia, the prevalence of diabetes ranges from 4-8%
(Mustaffa, 1990) and is expected to exceed 10% by the year 2020 (Anuar, 1997). This
means that with a 21 million population estimate in 1996, the number of diabetics in
Malaysia would number about 1. 7 million. Of these, about 95% would be having type 2
diabetes mellitus (Ministry of Health 1997). Management of this serious health threat
requires effective preventive and therapeutic measures. Prevention of diabetes either at
the primary or secondary level is directed primarily towards a change in lifestyle and
diet i.e. from a sedentary to a more physically active lifestyle coupled with a healthy
and balanced diet. Primary treatment of type 2 diabetes is mostly non pharmacological
i.e. diet therapy combined with exercise. This treatment modality has in fact been
recommended for the treatment of diabetes for over 2000 years and is still effective
when optimally utilised (Eriksson, 1999). Exercise is also one of the three main
approaches (including diet and education) to managing type 2 diabetes and impaired
glucose tolerance (IGT) patients in Malaysia (Ministry of Health, 1997). A trial of
therapy for at least 3-6 months of prudent exercise, diet and a healthy lifestyle should be
advocated before any OI:al hypoglycaemic agents (OHA) are prescribed. Even when
OHA are being used, emphasis should still be put on a proper diet, regular exercise and
compliance at all levels.
Guidelines on a suitable diet for type 2 diabetics are usually given by the attending
physician or when available by a resident dietitian. However advice on exercise is
usually provided by the attending physician based on the guidelines provided by the
Ministry of Health (Ministry of Health, 1997). As there will be different levels of
involvement in physical activity or exercise in different community groups (Walker et
al, 1999), the exercise programme prescribed has to be 'tailored' to suit the different
groups, especially so for the majority of type 2 diabetics who would most likely be
elderly and/or obese. The experience of the Universiti Sains Malaysia (USM) obesity
clinic has shown that obese subjects who underwent a proper weight reduction
programme in the form of dietary counselling, behaviour modification and exercise
achieved a significant amount of weight loss (Wan Manan et al, 1998). In another
similar study, dietary and physical activity intervention resulted in significant increase
in V02max and decrease in weight, body mass index (BMI), fasting glucose levels,
insulin, total cholesterol, triglycerides and systolic blood pressure. In this study the type
of exercise used was brisk walking, step aerobics or line dancing, 5 days a week (Wing
et al, 1998 ).
2
The current project aims at evaluating the effects of a structured exercise programme in
a group of type 2 diabetic patients at USM Kubang Kerian.
1.2 Study hypothesis
A well-managed and structured exercise programme can improve metabolic control,
body composition, lipid p.rofiles and cardiorespiratory fitness of type 2 diabetes mellitus
patients.
1.3 Objectives
1. To detennine the proportion of overweight (BMI > 25 kglm2) and obesity (BMI >
30 kg/m2) among type 2 diabetes patients.
2. To detennine the proportion of uncontrolled diabetes {HbAlc > 8%) or fasting
plasma glucose {FPG) > 7 mmoVl in type 2 diabetes patients.
3. To determine the proportion of hypertension {systolic blood pressure (SBP) > 140
mm Hg, diastolic blood pressure (DBP) > 90 mm Hg).
4. To detennine the levels of fasting plasma insulin and C-peptide in type 2 diabetes
patients.
5. To determine the levels of triglyceride, total cholesterol and high density
lipoproteins in type 2 diabetes patients.
6. To estimate the cardiovascular fitness of type 2 diabetes patients.
7. To assess the effects of a regular structured exercise programme on all the above
mentioned parameters.
8. To assess the knowledge, attitude and practice of exercise tn type 2 diabetes
patients.
3
1.4 Study Expectations
Exercise interventional studies done at other centers have shown positive changes in
metabolic control (FPG, HbAic, insulin, C-peptide levels), lipid profile, body
composition (body mass index (BMI), percentage body fat, fat free mass) and reduction
in blood pressure (Mourier et al, 1997; Yamanouchi et al, 1995; Lehmann et al, I 995).
The present study is an attempt at establishing a suitable and effective exercise
programme which could be easily followed by the local subjects and thus could
consequently produce similar positive changes in the metabolic control of type 2
diabetes patients.
4
2.1 Diabetes Mellitus
CHAPTER2
LITERATURE REVIEW
Diabetes mellitus is a group of metabolic disorders characterized by chronic
hyperglycemia resulting fr_9m abnormalities in insulin secretion, insulin action or both.
Diabetes is associated with long-term complications that affect almost every part of the
body. It is associated with long-term damage, dysfunction and failure of multiple organs
especially the eyes, kidneys, heart and blood vessels. The disease often leads to
blindness, heart and blood vessel disease, strokes, kidney failure, diabetic gangrene, and
nerve damage. Uncontrolled diabetes can complicate pregnancy, and birth defects are
more common in babies born to women with diabetes. Signs and symptoms of marked
hyperglycemia include polyuria, polydipsia, weight loss, and blurred vision. Growth
may be impaired and patients are more susceptible to infections. Acute emergencies of
diabetes include hyperglycemia with ketoacidosis or non ketotic hyperosmolar
syndrome. Patients with diabetes have an increased incidence of atherosclerotic
cardiovascular, peripheral vascular and cerebrovascular disease. Hypertension and
abnormalities of lipoprotein metabolism are often found in diabetic patients. The
emotional and social impact of diabetes and the demands of therapy may cause
significant psychosocial dysfunction in patients and their families.
2.2 Classification of Diabetes Mellitus
The World Health Organisation (WHO) Expert Committee on diabetes in 1980 and later
the WHO Study Group on Diabetes Mellitus ( 1985) recognized two major fonns of
diabetes; insulin-dependent diabetes mellitus (IDDM, type I diabetes) and non-insulin _
5
dependent diabetes mellitus (NIDDM, type 2 diabetes) including three other distinct